Difficult Conversations During a Pandemic


 

As providers, we continuously communicate with our patients and families. We listen to their medical histories, ask them to open wide, say aaahhh, take deep breaths, lie back to palpate the abdomen, and relax to elicit the patellar tendon response. We share the exam findings, summarize test results and recommend a treatment plan. That's a lot to fit into a 15 minute established patient slot. When everything goes well, we can feel like really effective communicators.

As a Hospice and Palliative Medicine physician, I have found that sharing bad or unexpected news and end-of-life discussions with patients and their families is more challenging. It doesn't usually fit very well into a regular workday, with the phone showing a queue of nurse case managers in their patients' homes needing orders and multiple text messages demanding urgent responses. While some of our hospice patients have suffered catastrophic illnesses or injuries, the vast majority are at the end of chronic illnesses they have managed for years. If anything, the multitude of incredible medical advances has made end-of-life conversations more complex. Many of our patients with heart disease have repeatedly enjoyed near-miraculous recoveries from the throes of death, thanks to new medications, procedures, and devices. Extraordinary advances in cancer treatments and interventions have transformed what used to be considered terminal illnesses into chronic diseases today. How do we know for sure this most recent relapse isn't reversible, until every available treatment and intervention has been tried? When do we switch gears and focus on comfort?

In the hierarchy of conversation complexity, however, COVID-19 is king. An 80-year-old woman was healthy, caring for her husband with dementia. Their son visited last month and unfortunately tested positive for COVID-19. None of the family members have been vaccinated. Two years ago, this scenario would not have meant much to me or my teammates. Today, it evokes a profound visceral response in every one of us. Because in this scenario, as in so many others today, both parents were hospitalized with pneumonia and hypoxia. Although they survived the acute illness, they were too weak to return home. So they were transferred to a skilled rehabilitation facility for physical therapy in hopes of giving them more time to recover and become stronger. However, over the ensuing weeks, both continued to decline to the point that now, they are bedbound, beginning to develop decubiti, and have almost completely stopped eating, despite all efforts to turn things around. Due to the recent Delta strain surge, their son has not been allowed to visit them in person and is confused by the different reports during phone conversations with various staff members on different shifts. Due to their extremely poor prognosis, their attending physician has consulted the Hospice Team to meet with them to determine hospice eligibility and discuss their goals of care.

COVID-19 creates an illness for which there is still a dearth of evidence-based practice, and my world has become a No Hubris Zone. During increasingly common scenarios such as this, donning and doffing for every patient encounter is becoming more automatic. However, it is still a challenge to sound compassionate and supportive through an N95, face shield, and goggles, while sporting the whole PPE ensemble of bouffant, gown, gloves, and shoe covers. I still sometimes struggle to find the right words, deal with the emotional reaction, fraught with temptations to assign blame, frustration at the lack of knowledge, and impotence to make a consistent difference in survival outcomes for these patients dealing with the terminal complications of this infectious disease.

In the midst of the daily shifting statistics, alert levels, and protocols in what feels like accelerating entropy, one over-arching theme seems to repeatedly emerge during each unique patient and family encounter when discussing serious news - Remember to Be.

  1. Be intentional: dedicate this moment to shut out distraction and focus on this patient/family before me, right now.
  2. Be curious: encourage them to express what they understand.
  3. Be empathic: seek to better understand their fears, desires, and needs.
  4. Be respectful: ask permission to share what I understand.
  5. Be clear: deliver serious news in a brief sentence, in their language.
  6. Be silent: giving them a chance to process this information that may have massive implications for their lives.
  7. Be observant: watch for and acknowledge their goals and emotional response.
  8. Be an advocate: come alongside, to be there with them in this situation.
  9. Be proactive: sum everything up and begin to look at next steps.
  10. Be committed: let them know I will walk with them through the storm ahead.

These are some of the medical lessons I am re-learning during this COVID-19 Pandemic. If there is any silver lining surrounding this pitch-black cloud, it consists of an opportunity for growth that may help me to also become a better wife, mother, sister, friend, and teammate. So to this year's list of task-oriented professional goals, I am adding two that focus on simply Being:

  1. Be Present.
  2. Be Kind.


Elizabeth Galfo, MD, FACP, FAAHPM, HMDC, hospice and palliative care medicine physician at St. Francis Reflections Lifestage Care, is a graduate of University of California in Davis, California and earned her medical degree from Oral Roberts School of Medicine in Tulsa, Oklahoma by receiving a full four-year Air Force Scholarship and ranked third in her class. She completed her internal medicine residency at Oral Roberts School of Medicine at City of Faith Hospital located in Tulsa, Oklahoma. In addition, Dr. Galfo has memberships in the following; American College of Physicians, American Academy of Hospice and Palliative Medicine, National Hospice and Palliative Organization, Alpha Omega Alpha Society and Phi Kappa Phi Society.

 
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